Further Inpatient Care
- Adults with a femur fracture are best treated with immediate operative fixation, typically intramedullary nailing.[7, 8, 9]
- Young children typically are treated with skeletal or skin traction for approximately 4 weeks, followed by a body spica cast.[10, 11, 12]
- Depending on the stage of skeletal maturity, some adolescents may be treated with initial external fixation, intramedullary nailing, or compression screw plate fixation.[13, 14]
- In the presence of contraindications to surgery, this repair may be delayed for days without significant complications if leg length is maintained with traction.[15]
- Open fractures require immediate operative debridement followed by delayed intramedullary nailing.[16]
Transfer
- Transfer patients with femur fractures when the fracture is immobilized adequately. This is best accomplished with a traction device. As an alternative, use a pneumatic or posterior molded splint.
- Reasons for transfer include the following:
- Lack of appropriate orthopedic staff or operative facilities at the presenting center necessitates transfer.
- Associated serious injuries, which are common, may require trauma center for ideal evaluation and management.
Complications
- Hemorrhagic shock
- Closed fractures of the femur can result in significant blood loss (eg, 1 L) within the thigh. Open fractures have the potential for even greater blood loss.
- Because of the high rate of associated injuries, actively seek out other sources of blood loss in patients with femur fractures and hypovolemic shock.
- Neurovascular injury
- Injuries to the neurovascular bundle are rare because of the large cushion of muscle protecting neurovascular structures.
- Compartment syndrome of the thigh does not occur often, and peroneal nerve contusion is seen occasionally.
- Infection: While open fractures are at high risk of soft-tissue and bony infection, postoperative infection is rare following repair of closed fractures.
- Respiratory demise: Fat embolism and adult respiratory distress syndrome (ARDS) can occur. Femur fractures at a level one trauma center have been associated with double the risk of developing ARDS (odds ratio [OR], 2.129; 95% confidence interval [CI], 1.382-3.278)[17] compared with other patients admitted for musculoskeletal injury. The risk trends upward with delays in surgical repair greater than 24 hours.
- More delayed complications include permanent stiffness of the hip or knee, shortening of the extremity, or malrotation, resulting in permanent deformity and decreased performance.
- Complications directly related to repair include (in order of increasing frequency) breakage of fixator hardware, nonunion, malunion, or delayed union.
- Finally, refracture has occurred at the initial injury site.
Prognosis
- Patients who survive the initial trauma associated with the injury typically heal well. Early mobilization following intramedullary nailing greatly reduces complications associated with prolonged immobilization.
- Age affects the speed and quality of recovery. Fractures may be caused by underlying medical conditions such as osteoporosis or cancer metastasis; these conditions may complicate recovery further.[18]
- Patients older than 60 years with closed fractures of femur have a mortality rate of 17% and a complication rate of 54%.[7]
Patient Education
- For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article, Broken Leg.
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Illgen R 2nd, Rodgers WB, Hresko MT, Waters PM, Zurakowski D, Kasser JR. Femur fractures in children: treatment with early sitting spica casting. J Pediatr Orthop. Jul-Aug 1998;18(4):481-7. [Medline].
Blasier RD, Aronson J, Tursky EA. External fixation of pediatric femur fractures. J Pediatr Orthop. May-Jun 1997;17(3):342-6. [Medline].
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